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Primary aldosteronism is an underdiagnosed and potentially treatable cause of secondary hypertension. We evaluated the incidence of clinically recognized primary aldosteronism among adults with clinically coded hypertension receiving intensive multidrug antihypertensive therapy in the TriNetX Analytics Network from 2010 through 2024. Among 1 888 042 eligible adults without prior primary aldosteronism, 1528 incident diagnoses were identified, corresponding to an incidence proportion of 0.081%, or 0.81 cases per 1000 patients. Diagnostic recognition varied by demographic subgroup and was highest among younger adults, males, Black or African American individuals, and Hispanic or Latino individuals. These findings suggest that documented recognition of primary aldosteronism in routine clinical practice remains low even among patients receiving intensive antihypertensive therapy. Because diagnoses were identified using electronic health record coding rather than systematic biochemical testing, results should be interpreted as clinical recognition rather than true disease prevalence.